| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
743 |
741 |
$19K |
| D1110 |
Prophylaxis - adult |
374 |
373 |
$14K |
| D1120 |
Prophylaxis - child |
417 |
416 |
$13K |
| D1206 |
Topical application of fluoride varnish |
514 |
513 |
$10K |
| D0274 |
Bitewings - four radiographic images |
197 |
197 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$1K |
| D0601 |
|
136 |
136 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$704.75 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$477.30 |
| D0602 |
|
43 |
43 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
29 |
$226.40 |
| D1330 |
|
42 |
42 |
$210.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$203.20 |
| D1999 |
|
41 |
40 |
$0.00 |